Complaints, Compliments and Feedback

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Please process this Complaints, Compliment or Feedback by completing below. The original feedback is lower on this form.
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Patient Complaints, Compliments and Feedback

Complete Dermatology is dedicated to quality health care of its patients. This form is provided to address patient complaints. Complaints must be in writing, dated and signed by the patient. Patient may have assistance writing the complaint, but the signature must be the patients; unless, the patient has a legal representative. Complaints will be reviewed personally by the practice manager. Complaints are addressed within seven (7) working days to include forwarding complaints to the appropriate staff/department and an optional Conclusion Letter sent to the patient. Patients may withdraw a complaint, in writing/dated; the investigation/process will end. All information is confidential; privacy and release of information regulations and laws apply. We would love to hear your thoughts, concerns or problems so we can improve or continue providing a great care for our patients and community! Please note you can remain anonymous if you would like and not complete the Name field.
Feedback Type*

ComplaintComplimentGeneral Feedback
Date Reported or discussed

MonthDayYear
Date
Identifying information is optional, but helpful for investigating and resolving cases.
Patient Name

First NameLast Name
Name of Parent or Guardian if Filing for a Minor Child

First NameLast Name
Patient Gender

MaleFemaleOtherPrefer not to say
Contact Phone Number
Please enter a valid phone number.(by providing this phone number, you agree to be contacted regarding this concern)
Email Address*
example@example.com - *Required if you would like a conclusion letter.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Complaint is Regarding:

ProviderClinical Staff (medical assistants and other ancillary staff)Front Office (reception)Billing
Please provide Complaint details: (Include dates, times, and names of practice personnel, if known)*
Was this discussed or reported to anyone? If so, who?
Please specify what Complete Dermatology could do differently for you the next time:
Please specify what remedies you are hoping for from Complete Dermatology:*
*Suggested resolution is not a guarantee and we will do our best to fairly evalulate each case.
Please attach any further documentation (copies of emails, forms, written statements etc)

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